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RA61 3  N21 3  Sickness  insurance  o 


National   industrial  conference  board. 

Sickness    insurance   or  sic knees   prevention* 


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Sickness  Insurance 

or 
Sickness  Prevention? 


Research  Report  Number  6 
May,  1918 


National  Industrial 
Conference  Board 


National  Industrial  Conference  Board 

15  BEACON  STREET,  BOSTON,  MASS. 


THE  National  Industrial  Conference  Board  is  a  co-operative 
body  composed  of  representatives  of  national  industrial 
associations,  and  organized  to  provide  a  clearing  house  of 
information,  a  forum  for  constructive  discussion,  and  machinery 
for  co-operative  action  on  matters  that  vitally  affect  the  indus- 
trial development  of  the  nation. 


Frederick  P,  Fish  Chairman 

Frederic  C.  Hood Treasurer 

Magnus  W.  Alexander         .        .       .        Managing  Director 


MEMBERSHIP 

American  Cotton  Manufacturers'  Association 

American  Hardware  Manufacturers'  Association 

American  Paper  and  Pulp  Association 

Electrical  Manufacturers'  Club 

Manufacturing  Chemists'  Association  of  the  U.  S, 

National  Association  of  Cotton  Manufacturers 

National  Association  of  Manufacturers 

National  Association  of  Wool  Manufacturers 

National  Automobile  Chamber  of  Commerce 

National  Boot  and  Shoe  Manufacturers'  Association 

National  Council  for  Industrial  Defense 

National  Erectors'  Association 

National  Founders*  Association 

National  Metal  Trades  Association 

Rubber  Association  of  America,  Inc. 

Silk  Association  of  America 

United  Typothet^  of  America 


SICKNESS    INSURANCE 

OR 
SICKNESS    PREVENTION? 


Research  Report  Number  6 

May,  191 8 


Copyright   1918 


National  Industrial  Conference  Board 

15   Beacon  Street 
Boston,  Mass. 


Foreword 

T7EW  problems  are  of  more  vital  interest  than  the 
conservation  of  health.  The  public  at  large  has  only 
a  faint  conception  of  the  extent  to  which  sickness  and 
physical  disability  sap  the  energies  and  impair  the  effi- 
ciency of  the  nation. 

A  broad,  constructive  program  for  dealing  with  this 
problem  is  a  national  need.  Thus  far,  legislative  attention 
has  been  directed  largely  toward  compensation  for  the 
wage  loss  suffered  by  disabled  workers  rather  than  toward 
sickness  prevention;  yet  the  desirability  of  preventing 
sickness  and  its  attendant  losses  is  obvious. 

Realizing  the  close  relationship  between  national  effi- 
ciency and  health,  the  National  Industrial  Conference 
Board  has  attempted  in  this  brief  report  to  emphasize  the 
enormous  burden  which  sickness  and  physical  disability 
place  on  society  and  industry  and  the  imperative  necessity 
for  a  thorough  study  of  the  practical  possibilities  of  a 
program  of  sickness  prevention  with  a  view  to  its  speedy 
adoption  as  a  national  policy.  Yet  this  should  be  done 
without  prejudice  to  the  principle  of  compensation  to  the 
extent  that  its  justification  may  be  demonstrated.  Ob- 
viously, however,  with  sickness  prevention  once  estab- 
lished as  a  national  policy,  and  with  an  efficient  system 
of  national  health  supervision,  the  necessity  for  resort- 
ing to  some  form  of  sickness  insurance  or  compensation 
would  be  very  greatly  reduced. 


Sickness  Insurance 

or 
Sickness   Prevention? 


The  Problem 


Of  2,500,000  men  examined  for  the  National  Army  in 
1917,  33%  were  found  physically  unlit  and  were  rejected.^ 
Of  every  100  residents  of  the  United  States  at  least  one  is 
afflicted  with  tuberculosis  in  some  form  and  a  larger 
number  with  some  organic  affection  of  the  heart.  From 
5  to  10%  of  adult  males  are  estimated  to  have  syphilis 
(either  inherited  or  contracted)  and  the  number  indirectly 
affected  by  this  insidious  disease  is  much  greater. ^  The 
proportions  of  those  affected  by  minor  ailments  and 
defects  are  higher  still. 

That  such  conditions  place  a  serious  handicap  upon  the 
social  well-being  and  productive  efficiency  of  the  nation  is 
obvious.  The  practical  question  as  to  how  they  shall  be 
dealt  with  demands  most  earnest  consideration.  Shall  the 
effort  of  the  state  and  of  private  management  be  directed 
chiefly  toward  prevention  of  sickness,  or,  instead,  toward 
relief  through  treatment  and  compensation  after  disability 
arises.^ 

In  legislative  discussion  of  the  subject  in  this  country 
chief  emphasis  has  been  laid  on  the  desirability  of  com- 
pensation for  sickness  rather  than  on  its  prevention;  yet 
the  wisdom  of  preventing  any  loss  which  can  economically 
be  avoided  is  indisputable.  Complete  elimination  of  the 
losses  arising  from  sickness  is  not  practicable,  but  if  a 
comprehensive  program  of  sickness  prevention  can  be 
made  to  yield  substantial  results  from  a  reasonable  ex- 
penditure, it  should  be  adopted.  A  first  step  is  to  obtain 
a  definite  idea  as  to  the  extent  of  sickness  and  how  far  it 
is  practically  preventable.  Then  an  estimate  of  the  cost 
can  be  made  and  its  justification  determined. 

^United    States    Provost    Marshal  General.    Report   to    the    Secretary  of 
War  on  the  First  Draft  under  the  Selective  Service  Act.     1917.      pp.  44,  45. 
'Some  estimates  run  higher.    See  p.  7. 

3 


Extent  of  Sickness 

Comprehensive  figures  as  to  the  extent  of  sickness  are 
not  available.  A  British  statistician,  Farr,  has  made  an 
estimate  that  for  every  death  there  are,  on  the  average,  two 
persons  constantly  sick.'  On  the  basis  of  the  annual  death 
rate  in  the  United  States  in  recent  years  —  about  14 
per  1,000  —  such  an  estimate  would  indicate  that  about 
3%  of  our  population  is  constantly  disabled  by  sickness 
and  that  on  the  average  every  man,  woman,  and  child 
loses  more  than  ten  days  per  year  through  illness. 

This  estimate,  however,  seems  rather  high.  The 
National  Conference  on  Industrial  Diseases,  held  in 
Chicago  in  1910,  estimated  that  a  total  of  284,750,000 
days  were  lost  through  sickness  by  the  33,500,000  men, 
women,  and  children  then  engaged  in  gainful  occupations 
in  the  United  States,  an  average  of  eight  and  one-half 
days  per  worker.^  This  is  in  striking  agreement  with  the 
results  of  sickness  surveys  made  by  the  Metropolitan  Life 
Insurance  Company  among  policyholders  and  others  in 
various  localities.  Seven  such  community  surveys  have 
been  made  by  the  company  in  widely  separated  localities 
which  included  a  large  variety  of  community  types.  A 
fair  percentage  of  the  total  population  of  each  place  was 
studied,  embracing,  of  course,  a  large  proportion  of  the 
wage-earning  population,  and  covering  in  most  instances 
periods  of  either  one  or  two  weeks. 

The  percentages  of  those  sick  and  the  percentages  of 
those  who  were  so  sick  as  to  be  unable  to  work  are 
given  in  the  following  summary. 

Percentages 
Unable 
Community  Survey  made  in  Sick       to  work 

Rochester,  N.  Y September,  1915  2.31  1.92 

Trenton,  N.J October,  1915  2.55  1.98 

State  of  North  Carolina April,  1916  2.85  2.29 

Boston,  Mass July,  1916  1.96  1.80 

Chelsea  Neighborhood,  N.  Y.  C.     .    .  April,  1917  1.48  1.38 
Cities  in  Pennsylvania  and  West  Vir- 
ginia:  (white  and  colored)    ....  March,  1917  1.96  1.85 

(colored)      March,  1917  2.31  2.18 

Cities  in  Pennsylvania  (white)     .    .    .  March,  1917  1.75  1.65 

Cities  in  West  Virginia  (white)    .    .    .  March,  1917  3.30  3.11 

Pittsburgh  (white) March,  1917  1.62  1.55 

Kansas  City,  Mo April,  1917  2.52  2.39 

Average,  all  surveys 2.02  1.88 

^Irving  Fisher.  Report  of  the  National  Conservation  Commission.  Vol. 
Ill,  p.  656. 

*W.  Gilman  Thompson.    The  Occupational  Diseases,     p.  10. 

4 


This  shows  that  on  the  average  2.02%  of  the  population 
studied  were  sick  and  that  1.88%  were  unable  to  work,  the 
proportions  varying  considerably  in  different  localities. 

With  respect  to  the  duration  of  illness,  the  Rochester 
survey  showed  that  50%  of  those  who  were  sick  had 
been  incapacitated  a  year  or  more;  the  Boston  survey 
showed  41.2%;  and  the  surveys  made  in  Pennsylvania 
cities,  24.7%.  In  Rochester  59.3%  of  individuals  too 
sick  to  work  were  found  to  have  been  ill  for  more  than  26 
weeks;  in  Boston,  50.1%;  in  Pennsylvania  (white  per- 
sons), 28.9%;  in  North  Carolina,  32.9%;  in  most  of  the 
other  surveys,  over  30%.^ 

The  foregoing  figures  cover  the  entire  population 
studied.  For  376,573  persons  15  years  of  age  and  over 
covered  in  these  surveys  the  average  loss  of  time  was 
8.4  days  per  year,  or  6.9  working  days,  based  on  300 
working  days  per  year.^  Females  showed,  on  the  average, 
a  slightly  higher  rate  of  disability  than  males. 

If  the  sickness  rates  disclosed  by  these  surveys  for  per- 
sons 15  years  of  age  and  over  hold  for  the  industrial  popu- 
lation of  the  entire  country,  the  annual  wage  loss  for 
40,000,000  workers  from  sickness  may  be  conservatively 
estimated  at  from  $500,000,000  to  $750,000,000. 


Prevalence  of  Physical  Defects  and  Disabilities 

Distinct  from  sickness  proper  but  extremely  important 
in  their  bearing  on  social  welfare  and  national  efficiency 
are  the  numerous  defects  and  disabilities  which  impair 
productive  capacity  and  which,  in  many  cases,  eventually 
result  in  disabling  diseases.  Mention  already  has  been 
made  of  the  high  percentage  of  rejections  among  recruits 
to  the  National  Army  in  1917.  Statistics  based  on 
portions  of  these  rejections  indicate  the  prominence  of 
such  physical  disabilities  as  defective  hearing  and  vision, 
decayed  teeth,  defects  of  the  nose  and  throat,  heart 
affections,  flatfoot,  and  minor  deformities  —  all  of 
which  constitute  physical  handicaps  that  must  interfere 

^The  figures  here  given  are  taken  from  the  reports  on  these  community 
sickness  surveys  as  published  by  the  Metropolitan  Life  Insurance  Company. 

^he  California  Social  Insurance  Commission,  in  a  report  dated  January  25, 
1917,  estimated  that,  among  wage-earnefs  in  that  state  "an  average  of  six 
days  per  person  is  lost  each  year  because  of  sickness." 


with  maximum  productive  efficiency  and  some  of  which,  if 
allowed  to  remain  uncorrected,  must  sooner  or  later  lead 
to  serious  illness  or  disability.  Undoubtedly  many  of 
these  defects  could  have  been  prevented  if  treated  in  early 
childhood. 

A  similar  examination  of  the  records  of  72,410  appli- 
cants for  service  in  the  United  States  Navy  for  1914 
shows  that  76%  were  rejected.  Of  the  total  number  of 
rejections,  14.97%  were  due  to  defective  vision,  8.61%  to 
defective  teeth,  10.77%  to  flatfoot,  7.48%  to  deformities, 
and  5.79%  to  heart  affections.  Study  of  the  rejections 
from  a  group  of  applicants  numbering  73,028  for  the  same 
service  in  1915  showed  practically  the  same  causes  and 
proportions  as  in  1914.  i 

Such  figures  disclose  an  unmistakably  widespread  preva- 
lence of  physical  disability  among  a  class  of  our  population 
which  should  be  in  its  prime.  Surely,  if  the  physical  con- 
dition of  these  applicants  disqualified  them  for  service 
in  the  Navy,  such  conditions  would  constitute  a  handicap 
to  them  in  other  lines  of  work  also. 

Feeble-Mindedness  and  Venereal  Disease 

Overshadowing  general  physical  defects  and  disabilities, 
but  largely  contributing  to  them,  are  two  factors  far- 
reaching  in  their  results  —  feeble-mindedness  and  venereal 
disease. 

It  has  been  stated  that  there  are  "at  least  four  feeble- 
minded persons  to  each  thousand  of  the  general  popula- 
tion," and  that  feeble-mindedness  produces  more 
pauperism,  degeneracy  and  crime  than  any  other  single 
force.  From  25  to  50%  of  the  inmates  of  our  prisons 
and  jails,  from  15  to  30%  of  the  inmates  of  almshouses, 
and  a  still  larger  percentage  of  prostitutes  are  attributed 
by  some  authorities  to  this  class.*  This  statement,  how- 
ever, utterly  fails  to  give  an  adequate  conception  of  the 
widespread  effects  of  feeble-mindedness.     Feeble-minded- 


'United  States  Bureau  of  Education.    Annual  Report,  1916.     Vol.  I,  p.  318. 

'H.  H.  Goddard.  Feeble-mindedness,  Its  Causes  and  Consequences,  pp. 
7-9, 15, 17;  Memorandum  submitted  to  the  Hospital  Development  Commission 
by  the  State  Charities  Aid  Association  and  the  New  York  Committee  on 
Feeble-mindedness.  New  York.  September,  1917.  pp.  8,  13,  14;  Helen 
MacMurchy.  The  Relation  of  Feeble-mindedness  to  Other  Social  Problems. 
In  National  Conference  of  Charities  and  Corrections.  Proceedings,  1916. 
p.  233. 

6 


ness  is  particularly  an  inherited  defect.  The  feeble- 
minded are  peculiarly  prolific,  and  the  feeble-minded 
parent  of  today  may  therefore  ultimately  become  re- 
sponsible for  a  great  number  of  public  charges.  This 
class  is  accountable  also  for  an  enormous  amount  of 
venereal  infection  and  other  sickness  which,  in  an  ever- 
expanding  progression,  exert  their  sinister  effect  on  the 
national  health. 

Mental  defectives  and  the  mentally  subnormal  also 
contribute  heavily  to  industrial  inefficiency.  Indeed,  it 
is  this  group  in  particular  that  constitutes  the  inefficient, 
irresponsible,  shifting  workers  of  industry.  While  low 
paid,  their  inefficiency  makes  them  the  high-cost  labor  of 
industry. 

Likewise  of  enormous  importance  in  the  burden  which 
they  throw  on  society  and  industry  are  the  venereal 
diseases.  For  instance,  to  gonorrhea,  more  prevalent 
than  any  other  disease  except  measles,  are  ascribed  6,000 
to  10,000  cases  of  blindness  annually  (equal  to  10%  of  all 
cases)  and  80%  of  blindness  in  the  new-born.  Gonorrhea 
also  results  in  many  chronic  diseases  of  both  men  and 
women  and  has  been  held  responsible  for  the  necessity  of 
a  very  large  percentage  of  all  abdominal  operations  in  the 
latter  sex.^ 

Syphilis,  as  has  been  stated,  is  estimated  to  affect  from 
5  to  10%  of  the  adult  male  population.  The  lower  esti- 
mate is  undoubtedly  conservative. "  Other  estimates  run 
as  high  as  15%  for  adult  males.  One  puts  the  percentage 
at  8  for  the  total  population.  To  syphilis  also  must  be 
charged  practically  all  locomotor  ataxia^  and  10%  of  all 
insanity.*  Syphilis  is,  moreover,  held  responsible  for  a 
large  proportion  of  the  diseases  of  the  heart,  blood  vessels, 
and  other  vital  organs,  and  for  more  deaths  than  are 
caused  by  diphtheria,  typhoid  fever,  scarlet  fever,  measles, 
whooping  cough,  and  influenza  combined.*  It  is  charged 
with  most  of  the  deaths  from  apoplexy  occurring  before 
middle  age.^    Of  the  deaths  from  softening  of  the  brain, 

'American  Social  Hygiene  Association.  Venereal  Diseases.  Pamphlet. 
1917.    p.  15. 

^William  Allen  Pusey.   Syphilis  as  a  Modern  Problem,  p.  106. 

'American  Social  Hygiene  Association.    Venereal  Diseases,    p.  16. 

*See  Frankwood  E.  Williams.  Relation  of  Alcohol  and  Syphilis  to  Mental 
Hygiene.     In  American  Journal  of  Public  Health.    December,  1916.    p.  1275. 

^Massachusetts  State  Department  of  Health.  First  Annual  Report  of  the 
Commissioner.     1915.     p.  20. 

'American  Social  Hygiene  Association.    Venereal  Diseases,    p.  16. 

7 


from  general  paralysis,  from  spinal  cord  diseases,  and  from 
cardiac  and  vascular  diseases  commonly  occurring  in  the 
form  of  angina  pectoris  and  arteriosclerosis,  one  in  four 
is  ultimately  chargeable  to  this  disease.  ^ 

Clearly,  if  the  ravages  of  these  insidious  diseases  and 
the  burden  of  feeble-mindedness  can  be  prevented  it  is  of 
the  utmost  importance  to  prevent  them. 

Vital  Concern  of  Industry  in  the  Problem 

While  the  problem  of  sickness  and  physical  disability 
affects  the  entire  population,  it  is  of  particular  concern  to 
industry.  In  practically  every  branch  of  industry  disease 
and  disability  cast  their  baneful  influence.  In  the  case  of 
garment  workers,  for  instance,  studies  by  the  U.  S.  Public 
Health  Service  show  that  nearly  3%  of  males  between 
the  age  of  20  and  44  years  were  affected  by  arteriosclerosis, 
a  similar  proportion  by  kidney  diseases  and  nearly  2% 
by  valvular  disease  of  the  heart.^  Similar  studies  of 
male  food  handlers  for  approximately  the  same  age 
groups  showed  that  about  7%  had  organic  heart  disease, 
33^%  diseases  of  the  arteries,  over  2%  cirrhosis  of  the 
liver,  and  a  similar  percentage  some  form  of  kidney 
disease. 3 

When  physical  defects  as  well  as  disease  are  included, 
the  proportions  run  very  much  higher.  For  instance,  of 
800  bakers  examined  in  New  York  for  the  army  and  navy, 
57%  had  some  disease  or  defect;  of  a  similar  number  of 
tailors  the  percentage  was  nearly  63;*  of  203  printers  and 
1,600  food  handlers,  it  was  only  a  little  below  70.^  Of  a 
group  of  2,086  male  garment  workers  practically  100% 
were  affected  by  some  disease  or  physical  disability.* 

'Albert  Scott  Warthin.  A  Plan  for  Combating  Venereal  Diseases  in  the 
State  of  Michigan.  Michigan  State  Board  of  Health.  Public  Health.  October- 
November,  1917.     pp.  482,  483. 

^U.  S.  Public  Health  Bulletin  No.  71.  p.  61. 

'Department  of  Health  of  the  City  of  New  York.  Monograph  Series  No.  17. 
August,  1917.     Table  facing  p.  8. 

^George  M.  Price.  Occupational  Diseases  and  the  Physical  Examination  of 
Workers.  In  Fifteenth  International  Congress  on  Hygiene  and  Demography. 
Washington,  1912.    Transactions,  Vol.  Ill,  Part  2,  p.  847. 

^James  A.  Miller.  Pulmonary  Tuberculosis  among  Printers.  6th  Inter- 
national Congress  on  Tuberculosis.  Washington,  1908.  Vol.  Ill,  pp. 
210-213;  Department  of  Health  of  the  City  of  New  York.  Monograph  Series 
No.  17.   Table  facing  p.  8. 

«U.  S.  Public  Health  Bulletin  No.  71.    pp.  54-61. 

8 


For  such  ailments  as  defective  teeth,  defective  vision, 
diseased  tonsils,  rhinitis,  spinal  curvature,  and  flatfoot, 
numerous  occupations  show  proportions  ranging  above 
25%,  sometimes  above  50%. 

To  say  that  the  existence  of  any  such  great  amount  of 
ill  health  and  physical  disability  among  the  nation's 
industrial  workers  is  a  serious  matter  is  merely  to  state  a 
truism.  Even  though  these  disabilities  may  not,  at  least 
in  their  earlier  stages,  cause  extended  absence  from  work, 
the  tax  thus  imposed  on  efficiency  must  be  a  heavy  one. 
Obviously,  maximum  efficiency  cannot  be  obtained  from 
a  force  of  workers  one  fourth  of  whom  are  suffering  from 
such  disabilities  as  defective  vision,  nasal  disorders,  and 
deformities,  or  whose  health  is  being  steadily  sapped  by 
tuberculosis,  alcoholism,  or  venereal  disease. 

For  most  of  the  sickness  and  disability  existing  among 
the  industrial  population,  industry  cannot  be  held  re- 
sponsible. Undoubtedly  some  disease  and  disability  have 
their  origin  within  the  factory.  In  the  case  of  so-called 
occupational  diseases  the  responsibility  of  Industry  Is  quite 
clear.  Yet  such  occupational  diseases  constitute  only 
a  modest  fraction  of  the  total  number  of  ills  to  which 
industrial  workers  are  victims.  For  instance,  of  5,121 
cases  studied  in  a  special  industrial  clinic  in  the  out-patient 
department  of  the  Massachusetts  General  Hospital  in 
1916,  in  only  466  was  a  definite  relationship  established 
between  the  patient's  defect  or  disability  and  the  hazard 
incident  to  his  work,  although  such  relationship  was 
indicated  in  a  considerably  larger  number  of  instances. 
The  466  cases  were  comprised  of  the  following:  lead 
poisoning,  148;  caisson  disease,  12;  "occupational 
strain,"  91;  industrial  dermatoses,  54;  anthrax,  18; 
occupational  neuroses,  22;  affections  of  the  respiratory 
tract,  56;  unstated,  65. ^ 

Tuberculosis  is  often  spoken  of  as  a  great  industrial 
disease.  Yet  it  is  a  very  much  disputed  question  as  to 
how  far  tuberculosis  is  fairly  chargeable  to  industry.  In 
a  vast  number  of  cases  responsibility  for  this  disease  must 
be  borne  in  large  measure  by  such  influences  as  heredity, 
housing  conditions,  and  personal  habits.  A  direct  con- 
nection between  the  prevalence  of  tuberculosis  and  con- 
gested housing  conditions  has  been  definitely  established 
by  many  studies.    Thus  one  survey  made  in  Berlin  showed 

Wade  Wright.  An  Industrial  Clinic.  Monthly  Review.  U.  S.  Bureau  of 
Labor  Statistics.    December,  1917.    pp.  185-188. 


that  42%  of  all  cases  of  tuberculosis  occurred  in  families 
occupying  but  one  room,  40%  among  those  occupying 
two  rooms,  12%  among  those  occupying  three  rooms,  and 
only  6%  among  those  occupying  four  or  more  rooms. 
Other  influences,  of  course,  undoubtedly  were  involved, 
but  these  statistics  and  many  others  of  a  similar  character 
emphasize  the  importance  of  housing  conditions  as  a 
factor  in  the  tuberculosis  problem,  i  The  social  and 
economic  conditions  underlying  such  housing  congestion 
must,  however,  also  be  considered. 

In  the  case  of  feeble-mindedness  and  venereal  disease, 
industry  clearly  is  the  victim  rather  than  the  culprit.  In 
an  apportionment  of  the  cost  of  dealing  with  these  prob- 
lems, whether  by  prevention  or  relief,  this  fundamental 
fact  must  be  definitely  recognized. 

Furthermore,  it  should  be  appreciated  that  industry  is 
concerned  not  alone  with  the  sickness  and  physical  disa- 
bility of  workers  actually  employed.  For  instance,  an 
industrial  manager  who  fancies  that  an  excessive  infant 
mortality  or  morbidity  rate  is  no  concern  of  his  takes  an 
extremely  narrow  view.  It  is  from  the  infants  of  the 
present  that  the  workers  of  the  future  must  be  recruited. 
Infant  conservation  is  but  another  phase  of  industrial 
preparedness.  Yet  of  all  deaths  in  the  United  States, 
those  of  infants  under  one  year  of  age  comprise  one- 
sixth, ^  and  fully  one-half  of  these  are  held  to  be  prevent- 
able. In  addition,  a  vast  number  of  defects  and  ills 
which  impair  efficiency  later  in  life  have  their  origin  in 
early  childhood  and  could  be  prevented  by  proper  treat- 
ment at  that  time.  Such  facts  demonstrate  that  the 
interest  of  industrial  managers  in  ill  health  and  disability 
is  by  no  means  confined  to  that  existing  within  the  walls 
of  their  factories.  They  also  demonstrate  that  these 
managers  should  take  an  active  and  intelligent  part  in  the 
working  out  of  an  effective  program  of  national  health 
conservation. 

How  Far  are  Diseases  and  Physical  Defects 
Preventable  ? 

That  a  vast  amount  of  disease  is  preventable,  not  only 
in  theory,  but  as  a  practical  measure  and  at  a  reasonable 
cost,    cannot    be    questioned.       Experience    with    such 

HJ.  S.  Public  Health  Bulletin,  No.  76.     Health  Insurance:  its  Relation  to 
Public  Health,   p.  23. 

'United  States  Census.   Mortality  Statistics,  1915.     p.  212. 

10 


diseases  as  typhoid  fever,  tuberculosis,  pneumonia,  and 
diphtheria  affords  convincing  evidence  that  the  oppor- 
tunity for  prevention,  in  the  field  of  communicable 
diseases  at  least,  is  very  great. 

Within  a  forty-year  period  the  death  rate  from  typhoid 
fever  has  in  many  communities  dropped  from  50,  75,  or 
more  per  100,000  population  to  10,  and  in  some  com- 
munities to  less  than  5.  For  the  entire  registration  area 
of  the  United  States  Census  the  rate  fell  from  35.9  per 
100,000  population  in  1900  to  12.4  in  1915.  The  death 
rate  from  tuberculosis,  which  in  1900  was  over  200  per 
100,000  population  for  the  registration  area,  has  in  recent 
years  been  cut  to  below  150. ^  Fully  as  striking  are  the 
results  attained  with  diphtheria,  and  certain  other  conta- 
gious diseases.  In  view  of  such  achievement,  extended 
discussion  to  demonstrate  the  practicability  of  a  pre- 
ventive program  in  the  field  of  communicable  disease  is 
superfluous. 

From  1895  to  1916  the  proportion  of  deaths  from 
communicable  diseases  to  total  mortality  in  Massachusetts 
decreased  from  28.6%  to  18.48%,  or  at  the  rate  of  nearly 
one-half  of  1%  per  year.^  There  seems  to  be  no  reasonable 
ground  to  doubt  that  broad  success  could  also  be  attained 
in  respect  to  many  non-communicable  diseases,  provided 
the  funds  and  a  suitable  organization  were  available. 

In  the  course  of  a  health  survey  made  in  one  of  the 
industrial  centers  of  Massachusetts,  physical  examination 
was  made  of  members  of  720  families.  The  total  number 
of  examinations  was  1,682.  Major  affections  were  found 
in  1,329  cases,  tuberculosis  in  48,  while  complicating 
illnesses  or  defects  were  reported  in  1,211  cases,  making 
the  total  number  of  affections  discovered  in  the  1,682 
examinations  no  less  than  2,588.  Of  this  total  number 
of  affections  55%  were  held  to  be  preventable.  The 
preventable  and  the  doubtful  groups  together  constituted 
84%  of  the  total  number  of  defects,  leaving  only  16%  in 
the  definitely  non-preventable  group. ^ 

The  diseases  most  frequent  in  the  industrial  popula- 
tion, other  than  strictly  "occupational  diseases,"  are  those 

^United  States  Census.  Mortality  Statistics.  1915.  pp.  21,  54,  58-142; 
see  also  Massachusetts  State  Department  of  Health.  Annual  Report.  1917. 
p.  221;  New  Jersey  Department  of  Health.  Public  Health  News.  August, 
1916.    p.  6. 

^Massachusetts  State  Department  of  Health.    Annual  Report,  1916.    p.  199. 

*D.  B.  Armstrong.  Community  Health  and  Tuberculosis  Demonstration. 
Manuscript. 

11 


of  the  degenerative  type,  such  as  Bright's  disease,  cancer, 
apoplexy,  cirrhosis  of  the  liver,  and  arterial  diseases. 
These  are  particularly  frequent  causes  of  disability  and 
death  after  the  age  of  45  years,  although  they  often 
exert  a  detrimental  eifect  on  the  efficiency  of  workers  at 
earlier  ages.  Predisposing  factors  which  contribute  to 
the  occurrence  of  those  diseases  often  exist  in  the  very 
early  periods  of  life.  While  opportunity  for  prevention 
of  these  diseases  may  be  less  promising  than  in  the  case  of 
communicable  diseases,  there  is  undoubtedly  a  large  field 
for  successful  preventive  work  if  undertaken  in  time. 

Many  of  these  diseases  are  attributable  in  part  to  over- 
indulgence in  alcoholic  liquors  and  to  the  ravages  of 
venereal  infection.  So  far  as  alcoholism  and  venereal 
diseases  are  concerned,  a  preventive  program  must  reckon 
with  the  factor  of  will  power,  which  makes  the  problem 
of  prevention  more  difficult.  Undoubtedly  such  diseases 
will  for  a  long  time  continue  to  tax  society  and  industry. 
Nevertheless,  even  here  the  opportunity  for  valuable  pre- 
ventive effort  cannot  be  questioned. 

Enough  has  already  been  accomplished  in  the  pre- 
vention of  many  diseases  which  have  their  origin  in  in- 
dustrial poisons,  skin  irritants,  fumes,  vapors,  and  dust, 
to  demonstrate  the  wisdom  of  more  intensive  prosecution 
of  such  work. 

With  respect  to  physical  disabilities  as  distinct  from 
sickness,  the  case  for  prevention  is  strong.  There  can  be 
no  question  that  many  ailments,  such  as  defective  hearing 
or  vision,  nasal  defects  and  many  throat  disorders,  which 
impair  efficiency  even  though  they  do  not  completely 
incapacitate  the  individual  for  work,  can  be  entirely  cured 
if  treated  in  time.  In  many  instances  where  complete 
cure  cannot  be  accomplished  a  radical  improvement 
certainly  is  possible. 

To  many  diseases  among  workers  of  the  larger  industrial 
centers  overcrowding,  poor  ventilation,  and  insufficient 
lighting  are  contributing  factors.  Such  conditions  clearly 
are  preventable. 

To  fail  to  apply  preventive  measures  to  such  illnesses, 
disabilities  or  conditions  as  will  almost  certainly  respond, 
and  instead  to  permit  them  to  go  uncorrected  until  the 
victim  becomes  a  charge  on  society,  is  absurd.  Certainly, 
if  the  state  can  contribute  to  the  support  of  individuals 

12 


after  they  become  Incapable  of  caring  for  themselves.  It 
can  contribute  to  prevent  them  from  becoming 
incapacitated. 


Comparative  Cost  of  Sickness  Prevention  and 
Compensation 

So  far  as  preventable  diseases  and  disabilities  are  con- 
cerned, the  advisability  of  their  prevention  can  be  ques- 
tioned only  on  the  ground  of  cost.  The  problem  in  the 
case  of  such  diseases  and  disabilities,  therefore,  is  to 
determine  whether  their  prevention  would  involve  an 
expenditure  out  of  proportion  to  the  probable  benefit. 

Conservative  estimates  of  the  cost  of  sickness  insurance 
(or  health  insurance,^  as  It  is  often  called)  set  the  total 
for  the  country  at  large  at  not  less  than  1720,000,000  and 
perhaps  not  less  than  $1,000,000,000  per  year.  An  ex- 
penditure of  $720,000,000  per  year  means  a  per  capita 
outlay  of  approximately  $7  for  each  man,  woman,  and 
child  in  the  country.  In  view  of  the  undeniable  fact  that 
In  nearly  all  programs  of  this  sort  the  cost  tends  to  Increase 
as  time  goes  on,  there  can  be  little  question  that  the 
adoption  of  the  compensation  principle  as  a  national  policy 
would  eventually  mean  a  still  larger  addition  to  the 
taxpayer's  burden.  European  experience  with  sickness  In- 
surance laws  and  our  own  experience  with  workmen's 
compensation  laws  clearly  indicate  that  their  cost  after 
but  a  few  years  of  operation  usually  greatly  exceeds  the 
preliminary  estimates.  The  fact  that  the  burden  of  an  In- 
surance program  would  be  heavy,  however,  is  not  the  fun- 
damental reason  for  questioning  Its  justification.  The  real 
consideration  is  the  strong  probability  that  the  expendi- 
ture of  only  a  modest  fraction  of  this  vast  sum  to  combat 
disease,  under  an  organized  program  of  prevention,  would 
avert  an  enormous  amount  of  sickness  and  disability.  The 
important  fact  already  noted  must  not  be  lost  sight  of, 
viz. :  that  the  greater  part  of  the  funds  expended  In  pre- 
ventive work,  if  wisely  used,  would  be  refunded  to  the 
community  in  the  form  of  production  which,  under  the 
insurance  system,  would  be  lost. 

Obviously,  the  cost  of  timely  correction  of  such  minor 
disabilities    as    defective   vision,    defective    teeth,    minor 


^In  this  report  the  term  "sickness  insurance"  has  been  adopted. 

13 


deformities  of  posture,  and  a  hundred  and  one  defects  of 
this  class  would  be  small  in  comparison  with  the  loss  which 
such  disabilities  might  directly  or  indirectly  entail  if 
allowed  to  go  unremedied. 

It  is  important  to  bear  in  mind  that  no  sickness  or 
health  insurance  program  yet  offered  purports  to  be 
available  for  the  benefit  of  the  entire  community,  or,  in 
fact,  for  even  all  of  the  industrial  population.  Usually  its 
benefits  are  restricted  to  manual  workers,  and  to  other 
wage-earners  whose  annual  earnings  fall  below  a  certain 
limit.  This  difficulty,  of  course,  can  be  met  by  extending 
the  scope  of  sickness  insurance.  But  if  the  limited  appli- 
cation already  proposed  involves  an  outlay  of  three- 
quarters  of  a  billion  dollars  or  more  annually,  it  is  apparent 
that  neither  its  adoption  nor  its  extension  is  a  matter  to 
be  lightly  accepted. 

The  estimated  cost  of  education  in  the  United  States  in 
1914,  including  private  as  well  as  public  institutions, 
aggregated  $754,500,000. ^  In  other  words,  the  educa- 
tional facilities  of  the  country  are  maintained  at  an 
estimated  annual  cost  less  than  the  estimated  cost  of 
sickness  insurance.  Education,  however,  is  in  no  sense 
the  counterpart  of  compensation,  but  is,  rather,  in  the 
same  class  as  preventive  work.  Obviously,  society  would 
not  tolerate  a  proposal  to  foster  a  system  whereby  the 
education  of  its  members  would  be  neglected  during 
youth,  and  instead,  compensate  by  a  system  of  cash 
benefits  those  who,  because  of  a  lack  of  education,  would 
later  be  unable  to  compete  successfully  in  the  struggle  for 
a  livelihood.  If  it  is  good  policy  to  safeguard  the  young 
by  fitting  them,  through  education,  for  their  life  work,  is 
it  not  equally  obvious  that  it  is  also  sound  policy^  to  safe- 
guard their  health  by  early  expenditure  to  prevent  sick- 
ness and  disability  rather  than  to  relieve  the  effects  of 
such  misfortune  by  belated  expenditures  for  compensa- 
tion? 

Experience  of  European  Countries  with   Sickness 

Insurance 
The  experience  of  those  European  countries  which  have 
adopted  sickness  insurance  on  a  comprehensive  scale  is 
illuminating.    A  striking  feature  of  this  European  experi- 

'Department  of  the  Interior.  Report  of  the  Commissioner  of  Education. 
1916.  Vol.  II,  p.  9.  Of  the  total  cost  here  given,  $486,166,000  was  for  public 
elementary  schools. 

14 


ence  is  that  the  average  number  of  days  lost  on  account  of 
sickness,  at  least  ostensibly,  has  steadily  increased.  In 
Germany,  for  instance,  out  of  every  100  insured  wage- 
earners  in  1890,  36.7  were  listed  as  sick  at  one  time  or 
another  during  the  year;  in  1913  the  proportion  was  45.6. 
In  Austria,  where  sickness  insurance  is  general,  the  corre- 
sponding figures  were  45.7  in  1890  and  51.8  in  1913.  Not 
only  has  the  number  of  cases  sharply  increased,  but  the 
average  number  of  days  lost  on  account  of  sickness  per 
sick  member  has  likewise  increased:  in  Germany,  from 
16.2  days  in  1890  to  20.2  in  1913;  in  Austria  during  the 
same  period,  from  16.4  to  17.4. 

Still  more  striking  is  the  increase  in  the  average  number 
of  days  lost  per  member  insured,  which  in  Germany 
rose  from  5.9  in  1885,  when  the  sickness  insurance  laws 
had  just  gone  into  effect,  to  6.19  in  1890  and  to  9.19  in 
1915,  while  corresponding  Austrian  statistics  from  1890 
to  1913  show  an  increase  from  7.98  days  per  member 
insured  to  9.45  days.^ 

It  may  fairly  be  argued  that  a  temporary  increase  in 
number  of  days  lost  does  not  necessarily  reflect  a  real 
increase  in  sickness.  It  might  even  indicate  greater 
prevention  by  which  more  serious  disability  would  be 
avoided.  For  instance,  absence  of  a  few  days  on  account 
of  an  incipient  cold  might  easily  forestall  an  absence  of 
several  weeks  because  of  pneumonia.  But  certainly,  if 
this  argument  holds,  the  temporary  increase  in  time  lost 
should  be,  because  of  quick  and  thorough  treatment, 
comparatively  small,  and  should  be  checked,  or  followed 
eventually  by  a  permanent  decrease.  The  fact  that  in 
these  countries  the  number  of  days  lost  through  sickness 
has  not  decreased,  but,  on  the  contrary,  has  steadily 
and  sharply  increased  over  an  extended  period,  discredits 
the  suggestion  that  it  is  due  to  greater  precaution.  The 
most  reasonable  interpretation  of  this  rise  in  the  sickness 
curve  in  Germany  and  Austria  under  sickness  insurance 
systems  is  that  it  reflects  a  growing  tendency  to  malinger 
and  take  advantage  of  the  sickness  benefits  provided. 
This  is  a  serious  and  exceedingly  practical  criticism  of  the 
operation  of  the  system  which  should  receive  most  careful 

^These  figures  quoted  from  Magnus  W.Alexander.  Some  Vital  Facts  and 
Considerations  in  Respect  to  Compulsory  Health  Insurance.  1917.  p.  11. 
See  also  Statistiches  Jahrbuch  fiir  das  Deutsche  Reich.  1892.  pp.  197, 
198;  United  States  Bureau  of  Labor  Statistics.  Monthly  Review.  May,  1916. 
p.  77;  November,  1916.  p.  127;  W.  Harbutt  Dawson.  Social  Insurance  in 
Germany,  1883-1911.    pp.  91,  94. 

15 


attention  in  considering  the  wisdom  of  introducing  it  in 
the  United  States.  Indeed,  the  history  of  European 
sickness  insurance  disbursements  strongly  suggests  a 
widespread  and  growing  disposition  on  the  part  of  the 
unscrupulous  to  profit  at  the  expense  of  the  honest.  Aside 
from  the  question  of  cost  and  fairness,  this  is  vitally  im- 
portant because  of  its  effect  on  the  morale  of  industrial 
workers. 

In  significant  contrast  to  this  experience  of  Germany 
with  compulsory  health  insurance  is  the  record  of  mutual 
societies  in  France  which  showed  a  rather  noteworthy 
decrease  in  the  average  days  lost,  while  in  Germany  the 
average  was  steadily  rising.  Thus,  for  the  so-called  free 
societies  of  France  (i.e.,  those  having  no  subsidy  from 
the  Government)  the  average  number  of  days  lost  through 
sickness  per  insured  member  fell  from  6.23  in  1898  to  3.87 
in  1910,1  whereas  in  Germany  the  average  rose  from  6.16 
to  8.53  (in  1911).  In  view  of  the  fact  that,  under  the 
mutual  system,  there  is  much  less  incentive  for  workers  to 
malinger,  this  radical  diff"erence  in  the  experience  of  the 
French  mutual  societies,  as  compared  with  the  compul- 
sory system  of  Germany,  seems  to  give  added  force  to  the 
suggestion  of  malingering  in  the  latter  country.  That 
malingering  is  common  under  the  German  system  is, 
indeed,  charged  by  many  German  authorities. 

Again,  the  experience  of  Great  Britain  with  its  National 
Health  Insurance  Act  has  by  no  means  been  wholly  satis- 
factory.    It  is  true  that  the  British  Medical  Society  in 
reviewing  the  first  five  years  operation  of  the  Act  took 
the  ground  that  on  the  whole  the  results  had  been  favor- 
able and  that  the  defects  in  the  Act  have  been  largely 
concerned   with   minor   administrative   details.     On   the 
other  hand,  the  Act  has  been  sharply  criticized  by  others, 
particularly  with  respect  to  disappointing  results  obtained 
in   sanatorium  work  in   the   case  of  tuberculosis.     The 
following  criticism  of  one  authority  seems  pertinent:' 
"The  fundamental  fault  in  the  national 
insurance   act,  from  the   point  of  view  of 
public  health,  is  that  it  does  little  or  nothing 
to  touch  the  great  environmental  causes  of 
disease.     It  is   palliative  rather  than   pre- 
ventive." 


'H.  G.  Villard.    Workmen's  Compensation  and  Insurance  in  France,  Hol- 
land, and  Switzerland.     1914.     p.  37. 

». William  A.  Brend,  m  The  19th  Century  and  After.   July,  1917. 

16 


This  statement,  which  is  merely  an  opinion,  is  not  pre- 
sented here  as  proof  that  the  National  Health  Insurance 
Act  in  Great  Britain  has  been  a  failure.  In  view,  however, 
of  the  obvious  difference  in  opinion  as  to  the  results  which 
have  been  achieved  under  that  Act  it  is  evident  that  a 
careful  investigation  into  its  operation  should  be  made 
before  accepting  the  British  legislation  as  a  basis  for 
action  in  this  country.  It  may  be  noted  that  the  cost  of 
health  insurance  in  Great  Britain  has  very  greatly  ex- 
ceeded the  preliminary  estimates. 

At  the  present  time  the  establishment  of  a  Ministry  of 
Health  is  being  vigorously  advocated  in  Great  Britain. 
Such  a  department,  if  organized,  would  devote  much 
effort  to  the  prevention  of  sickness. 

Experience  of  New  Zealand  and  Australia 

The  comparative  experience  of  New  Zealand  and 
Australia  with  the  infant  mortality  problem  is  likewise 
pertinent. 

In  New  Zealand  a  vigorous  educational  campaign  has 
been  carried  on  by  the  Government,  which  through  the 
agency  of  women's  and  children's  societies,  and  the 
establishment  of  women's  and  children's  hospitals,  has 
made  it  possible  for  a  large  proportion  of  mothers  in  both 
urban  and  rural  communities  to  obtain  advice,  nursing, 
and  medical  and  hospital  care.  In  1911  the  infant  death 
rate  in  New  Zealand  was  56.31  per  1,000  births.  In  1915 
it  had  fallen  to  50.05  per  1,000  births,  the  lowest  infant 
mortality  rate  in  the  world. 

In  Australia,  however,  the  Government  grants  a 
maternity  allowance  of  £5  for  each  child.  These  govern- 
ment grants  have  been  almost  universally  accepted  and 
the  total  expenditure  in  1916  reached  £662,035.  Never- 
theless, in  36%  of  all  births  the  mothers  were  not  attended 
by  a  physician.  The  infant  mortality  rate  in  Australia 
was  but  slightly  reduced,  falling  only  from  68.49  per 
1,000  births  in  1911  to  67.52  in  1915. 

While  the  great  excess  in  the  Australian  rate  over  that 
in  New  Zealand  may  not  be  entirely  attributable  to  the 
difference  in  methods  of  handling  the  infant  mortality 
problem,  the  general  similarity  of  conditions  in  the  two 
countries  gives  a  striking  significance  to  the  question  of 
method.  This  is  furthermore  pertinently  suggested  by 
the   fact    that    a    special    committee,    appointed   by   the 

17 


Australian  Commonwealth  to  investigate  the  problem  of 
infant  mortality,  reported  in  June,  1917,  to  the  Australian 
Parliament  that  there  was  urgent  necessity  for  the  adop- 
tion of  measures  in  Australia  similar  to  those  so  success- 
fully applied  in  New  Zealand. 

A  second  committee,  reporting  on  the  subject  in  August 
of  the  same  year,  called  attention  to  the  fact  that,  although 
there  had  been  a  slight  reduction  in  the  infant  death  rate 
in  Australia  since  the  introduction  of  the  cash  benefit 
system,  the  decrease  was,  nevertheless,  smaller  than  in 
the  preceding  year,  in  which  no  cash  benefits  were  paid.^ 

Prevention  the  Antithesis  of  Insurance 

It  has  often  been  claimed  that  a  sickness  insurance 
system  creates  a  new  economic  incentive  for  preventive 
work.  The  experience  of  the  European  countries  just  re- 
ferred to  does  not  support  this  contention.  Indeed  it  is 
difficult  to  see  any  logical  ground  for  the  claim;  a  clear 
appreciation  of  the  extent  of  sickness  and  disability  and 
the  heavy  burden  which  they  place  upon  society  should  be 
the  sufficient  and  powerful  incentive  for  prevention. 
Certainly  that  incentive  gains  no  force  by  confusing  it 
with  insurance,  the  very  antithesis  of  prevention.  If 
interest  in  prevention  can  be  aroused  through  an  insurance 
system,  it  should  be  much  more  sharply  stimulated  by  an 
organized  program  having  prevention  for  its  chief  object. 
Furthermore,  it  is  obvious  that  the  incentive  for  a  com- 
munity to  spend  large  sums  in  preventive  work  is  not  in- 
creased by  first  draining  its  resources  to  support  an 
expensive  system  of  treatment  and  insurance. 
h  As  contrasted  with  prevention,  the  chief  aim  of  sickness 
insurance  is  to  relieve  the  worker  from  the  effects  of,  or 
to  compensate  him  for  the  loss  resulting  from,  sickness  or 
disability  already  incurred.  In  most  legislation  of  this 
sort  the  proposal  is  that  the  victim  shall  be  com- 
pensated to  the  extent  of  a  portion  of  his  wages  for  a 
definite  period.  In  the  so-called  model  bill  prepared  by 
the  American  Association  for  Labor  Legislation,  which 
has  been  used  in  drafting  sickness  insurance  measures  in 
various  states,  the  plan  is  to  pay  the  sufferer  two-thirds 
of  his  wages  for  a  period  not  in  excess  of  twenty-six  weeks 
in  any  one  year.  This,  of  course,  is  a  very  definite  measure 
of  relief  and  one  which  the  wage-earner  can  readily  under- 

'United  States  Children's  Bureau.     Fifth  Annual  Report.  1917.  pp.  45-57. 

18 


stand;  the  payments  proposed  are  the  real  basis  for 
most  of  the  agitation  in  favor  of  sickness  insurance.  If, 
however,  the  wage-earner,  instead  of  being  compensated 
over  a  period  of  two,  ten,  or  twenty-six  weeks  to  the 
extent  of  two-thirds  of  his  wages,  can  be  saved  the  dis- 
abihty  and  consequent  loss  of  time  by  one-half  this 
outlay,  or  even  by  an  equal  expenditure,  it  is  clear  not  only 
that  he  is  himself  directly  benefited  but  also  that  society 
as  a  whole  secures  an  advantage;  because,  by  prevention, 
the  loss  of  production  which  would  result  if  his  disability 
were  permitted  to  run  into  serious  incapacitation  is 
averted. 


Present  Attitude  of  State  Legislators 

It  seems  significant  that  there  is  a  disposition  on  the 
part  of  legislators  in  the  United  States  investigating  the 
problem  to  go  cautiously.  Official  investigating  com- 
missions have  been  appointed  in  nine  states^  to  study 
sickness  insurance.  Four  of  these  commissions  (in  three 
states)  have  made  reports  which  are  available  for  study. 

The  first  Massachusetts  Commission  (1917)  investi- 
gated not  only  sickness  insurance,  but  also  old-age  pen- 
sions, unemployment,  and  hours  of  labor  in  continuous 
industries.  Four  of  its  nine  members  favored  the  adoption 
"of  a  general  system  of  health  insurance  for  wage-earners 
supported  by  enforced  contributions  from  employers, 
employees,  and  the  State."  One  member,  while  con- 
curring in  this  recommendation,  dissented  as  to  the  dis- 
tribution of  the  cost  until  more  "accurate  information  is 
available  based  on  Massachusetts  statistics."  Two  mem- 
bers urging  their  agreement  with  "the  aim  and  purpose  of 
health  insurance  to  conserve  the  health  of  the  wage-earner 
and  his  family"  nevertheless  opposed  specific  legislation 
"until  the  means  by  which  this  end  may  be  attained  are 
thoroughly  understood  and  the  public  opinion  is  formed 
on  the  subject."  The  remaining  members  contended  that 
"this  Commission  has  not  had  sufficient  time  to  study 
the  subject  thoroughly"  and  counseled  against  "im- 
mediate legislation. "2 


^California,  Connecticut,  Illinois,  Massachusetts,  New  Hampshire,  New 
Jersey,  Ohio,  Pennsylvania  and  Wisconsin. 

^Massachusetts  Special  Commission  on  Social  Insurance  Report.  Feb- 
ruary', 1917.     pp.  22,  37,  42,  43. 

19 


The  special  Massachusetts  Commission  which  reported 
in  January,  1918,  continued  the  study  begun  by  the 
previous  Commission,  Of  its  eleven  members,  nine  re- 
ported adversely.  The  two  dissenting  members  favored 
the  appointment  of  a  new  Commission  for  further  investi- 
gation, and  commended  a  non-contributory  plan  of 
insurance.! 

The  New  Jersey  Commissioners  recommended  the 
passage  of  a  workmen's  health  insurance  bill  adapted  to 
New  Jersey's  needs.  They  contended  that  special  emphasis 
should  be  placed  on  prevention  of  sickness  and  expressed 
the  opinion  "that  health  insurance  is  a  measure  which 
gives  great  promise  both  of  relieving  economic  distress 
due  to  sickness  and  of  stimulating  preventive  action. "'^ 

The  California  Commission  reported  that  "Health  in- 
surance of  wage-earners  would  mean  a  tremendous  step 
forward  in  social  progress,"  but  stated  that  'it  was  not 
"prepared  to  offer  a  plan  for  the  organization  of  health 
insurance."  The  Commissioners  saw  what  they  believed 
to  be  serious  objections  to  the  plan  (that  of  the  American 
Association  of  Labor  Legislation)  which  had  been  offered. 
They  sketched  a  plan  of  organization  which  they  thought 
to  be  free  from  certain  objections,  but  they  conceded  that 
this  substitute  plan  might  "be  open  to  objections  still 
more  grave. "^ 


Attitude  of  Organized  Labor 

A  number  of  labor  organizations  have  expressed  them- 
selves in  favor  of  the  principle  of  health  insurance,  notably 
some  of  the  international  textile  unions  and  the  inter- 
national typographical  union.  Several  state  federations 
of  labor  have  likewise  endorsed  the  principle  of  universal 
health  insurance;  in  many  cases,  however,  a  non-contri- 
butory plan,  which  would  throw  the  total  cost  either  on 
employers  alone  or  jointly  on  them  and  the  state,  was 
advocated.  On  the  other  hand,  it  may  be  noted  that 
Mr.  Samuel  Gompers,  President  of  the  American  Federa- 


%Iassachusetts    Social    Insurance    Commission    Report.      January,    1918. 
pp.  3&-55,  61-70. 

''New  Jersey  Commission  on  Old  Age  Insurance  and  Pensions.    Report  on 
Health  Insurance,     pp.  2,  19. 

'Report  of  the  California  Social  Insurance  Commission.    January  25, 1917. 
pp.  23,  123. 

20 


tion   of   Labor,    recently   expressed    himself   as    strongly 

opposed  to  the  system,  as  follows : 

"This  fundamental  fact  stands  out  para- 
mount, that  social  insurance  cannot  remove 
or  prevent  poverty.  It  does  not  get  at  the 
causes  of  social  injustice. 

"The  efforts  of  trade  organizations  are 
directed  at  fundamental  things.  They 
endeavor  to  secure  to  all  the  workers  a  living 
wage  that  will  enable  them  to  have  sanitary 
homes,  conditions  of  living  that  are  con- 
ducive to  good  health,  adequate  clothing, 
nourishing  food  and  other  things  that  are 
essential  to  the  maintenance  of  good  health. 
In  attacking  the  health  problem  from  the 
preventive  and  constructive  side  they  are 
doing  infinitely  more  than  any  health  in- 
surance could  do  which  provides  only  for 
relief  in  case  of  sickness,  and  yet  the  com- 
pulsory law  would  undermine  the  trade- 
union  activity.  There  must  necessarily  be 
a  weakening  of  independence  of  spirit  and 
virility  when  compulsory  insurance  is  pro- 
vided for  so  large  a  number  of  citizens  of 
the  state. "^ 
It  appears,  therefore,  that  even  among   those    whom 

sickness  insurance  is  intended  to  benefit,  there  is   very 

marked  difi^erence  of  opinion  as  to  its  desirability. 

Summary  and  Recommendations 

There  can  be  no  question  as  to  the  reality  or  the  great 
magnitude  of  the  burden  which  sickness  and  disability  now 
impose  on  the  nation.  That  one  out  of  every  three  young 
men  should  be  unfit  for  military  service  and  that  at  least  5 
out  of  every  100  of  the  entire  male  population  should  be 
infected  with  a  loathsome  venereal  disease,  which  is  in 
thousands  of  cases  transmitted  to  innocent  victims,  is  at 
once  a  reflection  on  national  health  standards  and  an  in- 
dictment of  present  health  conservation  programs.  An 
average  annual  loss  by  sickness  of  seven  workdays  by 
40,000,000  wage-earners  represents  the  loss  of  almost  a 
full  year's  production  for  a  million  workers.     The  esti- 

^Address  at  annual  meeting  of  National  Civic  Federation.  New  York, 
November  9,  1917. 

21 


mated  wage  loss  of  over  $500,000,000  per  annum  from 
sickness  —  which  takes  no  account  of  the  incalculable 
loss  due  to  impaired  efficiency  on  account  of  illnesses 
and  disabilities  that  do  not  result  in  absence  from  work 
—  exceeds  by  a  wide  margin  the  total  annual  dividends 
of  all  the  railroads  of  the  United  States;  in  a  decade  this 
loss  amounts  to  billions  of  dollars.  Yet  in  the  long  run 
the  monetary  loss  is  perhaps  the  least  important  phase 
of  the  problem. 

Such  conditions  call  for  a  vigorous  policy  of  remedial 
action.  Not  all  of  this  loss  is  preventable,  but  to  the 
extent  that  it  is  preventable,  the  desirability  of  prevention 
is  undeniable. 

That  sickness  insurance  would  afford  some  measure  of 
relief  cannot  be  denied.  Sickness  insurance,  however, 
proposes  to  reach  only  a  portion  of  one  class  of  the 
population.  It  makes  almost  no  provision  for  a  great 
number  of  disabilities  which  impair  efficiency  and  it 
leaves  practically  untouched  the  enormously  important 
problem  of  feeble-mindedness.  Yet  even  in  its  limited 
application  the  annual  cost  is  estimated  at  the  stupendous 
total  of  from  $700,000,000  to  $1,000,000,000;  that  either 
estimate  would  eventually  be  exceeded  is  practically 
certain. 

A  program  calling  for  any  such  expenditure  would  in 
any  case  challenge  critical  examination  and  compel 
convincing  demonstration  of  its  merit.  This  evidence  is 
not  to  be  found  in  the  experience  of  foreign  countries 
where  sickness  insurance  has  been  tried  and  where  on  the 
one  hand  it  has  failed  as  a  preventive  agency  and  on  the 
other  hand  has  placed  a  premium  on  inefficiency  and 
fraud.  But  even  if  it  had  worked  advantageously  in 
those  countries  the  wisdom  of  its  transfer  to  the  United 
States  where  social  and  poHtical  conditions  are  so  radically 
different  would  not  necessarily  follow. 

Underlying  these  considerations  is  the  fundamental 
fact  that  all  sickness  and  disability  which  can  reasonably 
be  prevented  should  be  prevented  instead  of  being 
allowed  to  remain  unremedied  until  they  impose  a  burden 
of  misery  and  poverty  on  the  individual  and  a  burden  of 
cost  on  society. 

Preventive  work  in  the  case  of  such  communicable 
diseases  as  typhoid  fever,  tuberculosis,  pneumonia,  and 
diphtheria  has  been  brilliantly  successful.      That  in  less 

22 


I 


than  a  generation  the  mortality  rate  for  tuberculosis  per 
100,000  population  has  fallen  from  over  200  to  less  than 
150  and  that  for  typhoid  fever  from  35.9  to  12.4  is  a 
tribute  to  the  efficiency  of  prevention,  since  in  the  main 
these  results  have  been  accomplished  by  preventive 
agencies.  The  results  already  attained  with  a  compara- 
tively modest  expenditure  in  this  field  are  an  earnest  of 
the  possibilities  of  still  greater  progress  in  the  future  and  of 
broad  success  in  the  field  of  non-communicable  diseases  as 
well,  if  these  are  attacked  under  a  definite  policy  with  a 
permanent  and  efficient  organization  and  sufficient  funds. 

The  results  already  achieved  in  sickness  prevention 
through  local  effort  with  limited  funds  establish  beyond 
a  doubt  the  urgent  need  for  a  thoroughgoing  investigation 
of  its  further  possibilities  under  a  definite  national 
policy.  Such  an  investigation  should  be  undertaken  at 
once.  The  withdrawal  from  production  of  hundreds  of 
thousands  of  the  most  robust  workers  for  military  service 
has  already  Increased  the  relative  importance  of  the  sick- 
ness burden  as  related  to  national  efficiency,  and  it  will  be 
accentuated  by  further  withdrawals  as  the  war  goes  on. 

Since  the  occurrence  and  the  results  of  sickness  are 
nation  wide  and  not  local,  such  an  investigation,  to  be 
effective,  must  be  conducted  by  some  federal  agency, 
possibly  the  United  States  Public  Health  Service,  under 
the  authority  of  Congress  and  with  an  appropriation  suffi- 
cient to  permit  of  thorough  work  and  conclusive  results. 
The  first  task  of  such  a  national  health  commission  should 
be  to  determine  broadly  the  nature,  extent,  and  causes  of 
sickness  and  physical  impairment  in  the  United  States, 
the  limits  within  which  a  sickness  prevention  program 
can  be  practically  applied,  a  careful  estimate  of  Its  cost, 
and  a  scheme  for  Its  actual  administration,  utilizing,  as 
far  as  possible,  existing  agencies  already  engaged  In  pre- 
ventive work  but  co-ordinating  them  in  such  manner  as 
to  avoid  unnecessary  duplication  of  effort  and  expense. 
The  commission  should  submit  a  comprehensive,  analyti- 
cal, and  constructive  plan  at  the  earliest  date  consistent 
with  thoroughness. 

It  is  not  the  province  of  this  report  to  outline  details 
of  a  final  plan  or  even  of  a  preliminary  survey.  Clearly 
an  investigating  commission  is  bound  to  take  account  of 
such  salient  features  of  the  problem  as : 

23 


Reduction  in  infant  mortality. 

Supervision  of  the  health  of  school  children,  including 
treatment  of  various  common  defects. 

Systematic  instruction  in  personal  hygiene,  diet  and  living 
conditions;  improvements  in  sanitation,  housing,  and  milk 
and  water  supply. 

Extension  of  free  hospital  and  free  clinical  agencies. 

Treatment  of  feeble-mindedness  and  venereal  diseases. 

The  effect  of  occupation  on  health  of  workers. 

Periodic  physical  examination,  not  only  of  industrial 
workers  but  of  the  entire  population,  is  another  import- 
ant matter  for  consideration.  Such  a  commission  may 
also  very  properly  consider  whether  and  to  what  extent 
nationalization  of  medicine  may  be  advantageous. 

So  far  as  strictly  occupational  diseases  are  concerned, 
where  the  responsibility  of  industry  can  be  clearly  estab- 
lished, these  apparently  can  be  most  effectively  dealt  with 
on  a  workmen's  compensation  basis.  For  this  purpose 
it  may  be  desirable  to  amend  existing  workmen's  com- 
pensation acts  to  include  such  diseases  or  to  make  pro- 
vision by  separate  statute,  leaving  their  administration, 
however,  to  workmen's  compensation  boards  in  order  to 
avoid  new  administrative  expenditures. 

In  thus  urging  a  searching  study  of  the  merits  of  a 
preventive  policy  there  is  no  desire  to  prejudice  unfairly 
any  proper  or  necessary  measures  for  alleviating  unavoid- 
able sickness  and  disability  or  for  dealing  with  individual 
cases  worthy  of  special  consideration.  Under  some  con- 
ditions and  in  a  certain  field  the  compensation  principle 
may  be  justified.  But  at  least  it  is  imperative  to  narrow 
that  field  wherever  practicable.  The  simple  fact  should 
never  be  lost  sight  of  that  successful  prevention  of  sickness 
eliminates  the  necessity  for  compensation.  Furthermore 
every  dollar  successfully  and  economically  spent  in  pre- 
ventive work  is  a  dollar  invested  in  productive  enterprise. 

First  a  national  study  of  prevailing  sickness  and  its 
causes;  then  a  national  program  for  the  prevention  of 
all  preventable  sickness,  with  liberal  but  Intelligent  pro- 
vision for  unpreventable  sickness  through  compensation 
or  otherwise,  as  a  duty  of  society  to  its  members: — this 
Is  submitted  as  a  rational,  constructive  and  humane 
program  for  dealing  with  the  sickness  problem  In  Its 
individual  as  well  as  its  social  and  industrial  aspects. 

24 


Publications 

of  the 
National  Industrial  Conference  Board 


Research  Re-port  No,  1.    Workmen's  Compensation  Acts  in 
THE  United  States  —  The  Legal  Phase.     62  pages. 
April,  1917.    31.00. 
Summary  of  Research  Report  No.  1.     8  pages. 

Research  Re-port  No.  2.  Analysis  of  British  Wartime  Re- 
ports ON  Hours  of  Work  as  Related  to  Output  and 
Fatigue.    57  pages.    November,  1917.    31.00. 

Research  Report  No.  S.  Strikes  in  American  Industry  in 
Wartime.    20  pages.    March,  1918.    50  cents. 

Research  Report  No.  4-  Hours  of  Work  as  Related  to  Out- 
put AND  Health  of  Workers  —  Cotton  Manufac- 
turing.   64  pages.    March,  1918.    31.00. 

Research  Report  No.  5.  The  Canadian  Industrial  Disputes 
Investigation  Act.    28  pages.    April,  1918.    50  cents. 

Research  Report  No.  6.  Sickness  Insurance  or  Sickness 
Prevention?    24  pages.    May,  1918.    50  cents. 

Research  Report  No.  -.  Hours  of  Work  as  Related  to  Out- 
put and  Health  of  Workers  —  Boot  and  Shoe 
Manufacturing.    [I-n  preparatio-n.] 

Research  Report  No.  -.  Hours  of  Work  as  Related  to  Out- 
put AND  Health  of  Workers  —  Wool  Manufactur- 
ing.    [I-n  preparatio-n.] 

Research  Report  No.  -.  Hours  of  Work  as  Related  to  Out- 
put AND  Health  of  Workers  —  Silk  Manufactur- 
ing.    [I-n  preparation.] 

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